The JIM interview John G. Clarkson, MD.

Located in one of the fastest growing areas in the United States, the University of Miami School of Medicine sits poised to capitalize on an expanding hemispheric economy. At the same time, the school must also accommodate a burgeoning competition for Medicare patients with for-profit hospitals. At the helm of the University of Miami School of Medicine is John G. Clarkson. Clarkson had served as chairman of the Department of Ophthalmology, Bascom Palmer Eye Institute and medical director of the Anne Bates Leach Eye Hospital from 1991 to 1995, when he became dean. He replaced Dean Bernard Fogel who held the position for 14 years. Interviewed in his office in sunny Miami, Clarkson discussed Miami's approach to expanding the school's foreign and domestic patient base, developing alliances, and trying to increase the medical center's profile amongst an increasingly diverse population.

Asymmetric canthaxanthin retinopathy.

PURPOSE/METHODS: We studied a case of crystalline retinopathy occurring after prolonged use of oral canthaxanthin. The patient was followed up for 38 months during which time she sustained a branch retinal vein occlusion in her left eye. RESULTS/CONCLUSIONS: An asymmetric appearance to the crystalline deposition was noted with increased sedimentation seen in the left eye. Vascular alterations after a branch retinal vein occlusion may lead to local stasis that may exacerbate the development of canthaxanthin retinopathy.

The ocular manifestations of sickle-cell disease: a prevalence and natural history study.

Prophylactic photocoagulation may have a role in the treatment of proliferative sickle retinopathy in selected patients with SC disease, but none of the studies reported to date have established that such treatment of these eyes improves the long-term visual outcome as compared with the natural history as documented in this study. The similar visual outcomes in the eyes reviewed in this natural history study as compared with those that have been treated with photocoagulation should not be unexpected, because there is greater predilection for spontaneous involution or autoinfarction of the neovascular tissue in SC disease as opposed to the neovascularization that develops in other retinal vascular disease. A controlled, multicenter clinical trial designed to study those eyes at greatest risk should be considered. Such a trial should specify patient age (15 to 30 years), hemoglobin type (SC disease), and a minimum threshold of active proliferative disease (60 degrees or greater). Such criteria have been suggested by others. By comparing the outcome of eligible eyes randomly assigned to treatment or observation and followed for an extended period, it will be possible to learn whether laser photocoagulation offers a better prognosis than the natural history of proliferative sickle retinopathy. There is no question that in some eyes with proliferative sickle retinopathy, nonclearing vitreous hemorrhage and/or retinal detachment will develop. Clear definition of the risk factors leading to these advanced stages, however, is lacking, and the value of treatment is uncertain.

Results and complications in treated retinal breaks.

One hundred sixty-four patients (171 eyes) were treated for retinal breaks and the treatment outcomes were studied. One hundred two eyes were acutely symptomatic, 22 eyes were chronically symptomatic, and 47 eyes were asymptomatic. The reasons for further treatment in 38 of the 171 eyes (22%) included the following: (1) inadequate closure of the original break without detachment in eight eyes (5%), (2) new breaks without detachment in 15 eyes (9%), (3) an operation for retinal detachment caused by the original break in seven eyes (4%), or (4) retinal detachment caused by a new break in eight eyes (5%). Failure rates of treatment among acutely symptomatic, chronically symptomatic, and asymptomatic subgroups were not statistically significant. The risk of treatment failure was higher for aphakic and pseudophakic eyes, and in eyes with peripheral retinal abnormalities in the fellow eye. Among 38 patients with failed treatments, 20 (52%) returned for further examination within one month of initial treatment, whereas eight of the 38 patients with failed treatments (21%) returned six months or more after initial treatment. Peripheral retinal abnormalities were recognized initially in 65 of the 171 fellow eyes (38%) and subsequently developed in nine of the fellow eyes (5%) during the follow-up interval. Further treatment is often necessary after initial treatment of peripheral retinal breaks, emphasizing the need for careful long-term follow-up care.

Evaluation of eyes with advanced stages of retinopathy of prematurity using standardized echography.

The authors evaluated 36 patients (72 eyes) who had either Stage 4 or Stage 5 retinopathy of prematurity (ROP) with standardized A-scan and B-scan echography. The eyes were evaluated for vitreous opacities, retrolental membranes, and retinal detachments. Stage 5 retinal detachments were present in 94% (68 of 72) of the eyes with 65% (47 of 72) having a wide anterior and narrow posterior configuration. Anterior retinal loops were noted in 36% of the eyes. Subretinal opacities were present in 47% of the eyes. Choroidal thickening and intraocular calcium were noted in 22% and 14% of eyes, respectively. The axial eye length was measured and adjusted for the differences in chronological and gestational age and compared with data from normal eyes. This showed that eyes with ROP were much smaller. The standardized A-scan was helpful in confirming the diagnosis of retinal detachment, evaluating the peripheral retina, and examining the subretinal space. The combination of A-scan and B-scan echography is helpful in predicting anatomic findings in patients with ROP undergoing surgery.

Macroaneurysms associated with retinal branch vein occlusion.

We reviewed the clinical findings, color photographs, and fluorescein angiograms of 147 patients (154 involved eyes) who participated in the Branch Vein Occlusion Study through the Bascom Palmer Eye Institute for the presence of macroaneurysms within or adjacent to the zone of branch vein occlusion. Four distinct categories of macroaneurysms included arterial, venous, capillary, and collateral-associated types. We identified 59 lesions among 25 of the 154 (16.2%) affected eyes. Intraretinal lipid exudation and hemorrhage were commonly observed around the lesions, but these complications usually did not affect visual acuity. Macroaneurysms were associated with capillary nonperfusion on fluorescein angiography. Retinal neovascularization occurred in eight of 25 eyes (32%) with macroaneurysms.

Endogenous Candida endophthalmitis. Management without intravenous amphotericin B.

Eight consecutive cases of culture-proven endogenous Candida endophthalmitis (ECE) were managed between 1980 and 1988. All patients were treated with vitrectomy and injection of intravitreal amphotericin B. Blood cultures were negative in all patients, although Candida albicans was cultured from a foot ulcer in one patient. No systemic therapy was used in three patients, three patients received oral ketoconazole, and two patients received oral flucytosine postoperatively. Intravenous amphotericin B was not used because of lack of evidence of disseminated candidiasis and the systemic toxicity associated with its use. The ECE responded favorably to treatment in all cases. Final vision was better in patients with a shorter interval between onset of symptoms and initiation of antifungal therapy. Posttreatment visual acuities were: four eyes greater than or equal to 20/50, two eyes at 20/80 to 20/200, and two eyes less than 5/200. This series showed that ECE without evidence of disseminated disease can be treated successfully with vitrectomy and intravitreal amphotericin B.

Surgical management of late-onset retinal detachments associated with regressed retinopathy of prematurity.

The authors report their experience in managing 16 cases of late-onset retinal detachments (RDs) associated with regressed retinopathy of prematurity (ROP). Fourteen (88%) of the 16 eyes were successfully reattached. An initial scleral buckling procedure was successful in 6 of 12 eyes. A pars plana vitrectomy was necessary in a total of eight eyes that either initially presented with proliferative vitreoretinopathy (1 case), posterior retinal breaks (1 case), subretinal fibrosis (1 case), vitreoretinal traction bands (1 case), or had persistent vitreoretinal traction after failed scleral buckling procedures (4 cases). Visual acuity stabilized or improved in 13 of the 14 eyes with successful retinal reattachment. Because these cases often have significant vitreoretinal traction and/or posterior retinal breaks, pars plana vitrectomy in conjunction with scleral buckling may be necessary in order to achieve long-term retinal reattachment.

Management options for retinal detachment in the presence of a posteriorly dislocated intraocular lens.

Six consecutive cases of retinal detachment occurring in the presence of a posteriorly dislocated intraocular lens were managed between 1978 and 1988. In three cases, a standard scleral buckling procedure was performed with successful retinal reattachment, leaving the dislocated implant in the inferior formed vitreous. In two cases, the implant was removed through the pars plana at the time of pars plana vitrectomy, fluid/gas exchange, and scleral buckling procedure. In the remaining case, the intraocular lens was repositioned with scleral fixation sutures after pars plana vitrectomy, fluid/gas exchange, and scleral buckling. All cases achieved and maintained retinal reattachment with visual improvement. Recommendations for management are discussed.

Evaluation of eyes with stage-5 retinopathy of prematurity.

Recent advances in vitreous microsurgical techniques described by Machemer, Charles, Hirose, Trese, de Juan, and others have resulted in successful anatomical reattachment of eyes with stage-5 retinopathy of prematurity (ROP). Such eyes had previously been classified as inoperable. Although nearly 50% of eyes achieve an anatomical reattachment of the posterior retina, from 10% to 30% of the reattached eyes reported to date have no light perception. Infants with stage-5 ROP in both eyes may be quite difficult to evaluate preoperatively, particularly with regard to visual function and the configuration of the retinal detachment. Protocols for obtaining a bright flash visually evoked potential (VEP) and standardized echography have been developed to determine the following: 1. Objective evidence of visual function in one or both eyes 2. The configuration and characteristics of the retinal detachment It is hoped that such prospective evaluation will help to identify those eyes with the best prognosis for both visual anatomical success.

Acute multifocal hemorrhagic retinal vasculitis.

The authors present a series of seven patients with acute visual loss associated with mild anterior uveitis, multifocal retinal vasculitis, retinal capillary nonperfusion, retinal hemorrhage, disc swelling, and vitreitis. Oral prednisone was of some benefit in these patients and oral acyclovir was generally ineffective. Neovascular complications including retinal, disc, choroidal, and iris new vessels were common, requiring photocoagulation in five patients. Horseshoe tears developed in two patients in zones of uninvolved retina but retinal detachment did not occur. The etiology remains unknown, although it may represent either a localized ocular form of Behçet's disease or other systemic syndrome, infection with a herpes group virus other than zoster varicella virus, or a manifestation of an undefined infectious agent.

Pars plana vitrectomy in the management of complications of proliferative sickle retinopathy.

Ten patients (11 eyes) with sickle-C hemoglobinopathy with complications of proliferative sickle retinopathy were treated using pars plana vitrectomy with or without the use of a scleral buckle. Postoperative visual acuity was improved in ten of 11 cases. Three cases of retinal detachment were managed by internal vitreoretinal techniques alone without the use of a scleral buckle. Although exchange transfusions were used in only five of the 11 cases, no cases of recognized anterior segment ischemia occurred during the postoperative course of these patients. Because of exchange transfusion risks and awareness of intraoperative and postoperative measures to reduce this complication, the use of exchange transfusions probably should be discontinued as prophylaxis for vitreoretinal surgery in these patients.

Hypodermic stainless steel tacks and companion inserter designed for peripheral fixation of retina.

Mechanical fixation of the torn or cut edge of retina with 30-gauge hypodermic stainless steel tacks has been performed in 15 patients at the Bascom Palmer Eye Institute, Miami, and Miami Veterans Administration Medical Center with six to 18 months of follow-up. The companion tack inserter allows the surgeon to select an angle for the shaft of the tack in relation to the inserter to allow the tack to be driven perpendicularly into sclera even when the insertion is anterior to the equator. If residual detachment remains following fluid-gas exchange after preliminary placement of the retinal tacks, a given tack may be removed and reinserted to facilitate complete retinal reattachment. This utilitarian feature allows the surgeon to eliminate residual anteroposterior traction following complete membrane peeling by extending relaxing retinotomies and tacking the posterior cut edge of the retina securely between the ora serrata and the equator.